Case 149: PCI Manual - Truly resistant lesion

A patient with prior CABG presented with medically refractory angina. She had a 90% in-stent lesion of the distal left main and the proximal circumflex. She had patent LIMA-LAD and SVG-OM, but the proximal LAD, OM1 and OM2 and left PDA were filling via the left main. The left main had been previously stented but the stent was under-expanded. Left main PCI was offered to the patient.

The circumflex was wired with a Viper Flex Tip wire but the orbital atherectomy crown could not reach the left main lesion. We were unable to insert another guidewire and the patient developed chest pain and ST segment depression. A Sapphire 1.0 mm balloon failed to cross the left main despite using a Guidezilla guide catheter extension. We could not deliver a Turnpike LP or a FineCross microcatheter. Multiple passes were performed with the 0.9 mm laser that failed to cross the lesion as well. The Sapphire balloon failed again to cross but a monorail Threader balloon was successfully delivered to the left main using the “independent hand” technique with resolution of the chest pain and ST segment changes. Orbital atherectomy was performed but the lesion remained partially balloon undilatable despite multiple balloon inflations and with a NC and a Scoreflex balloon. Intravascular lithotripsy was performed with better lesion expansion followed by stenting with a 3.5x18 mm DES. The patient had recurrent chest pain and ST segment depression. After balloon angioplasty of the jailed LAD the chest pain and ECG changes resolved.

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2:26 balloon uncrossable algorithm
4:36 independent hand technique
5:03 balloon undilatable algorithm